The pain of changing health plans

A Northern View

November 4, 2012

Recently I was diagnosed with a ruptured Baker's cyst on my left knee, leaving me with an enormous amount of pain, fluid on my knee, and the need to see an orthopedic surgeon and a prescription for physical therapy for the third time in my life.

As we all know, with medical problems come having to deal with the insurance company.

In the past, my experience getting what I need and getting to see who I need to so I can get healthier has been a relatively pain-free experience. But since the day that my dad's work switched from offering a "Preferred Provider Option" to a "Health Maintenance Organization," through a different provider, dealing with the insurance hassles has been more painful than any injury I've ever had.

Article Photos

Adelle Whitefoot

For those of you lucky enough not to know much about HMOs, they do cover my bills fairly well, but to get them to pay for anything requires doing a series of backflips through fiery hoops. My HMO requires me to see a doctor who is approved by the insurance company - and all referrals must come from that doctor and that doctor alone.

For example, I got a referral from the hospital to see an orthopedic surgeon when the rupture first occurred, but because the referral did not come from my network-approved primary physician it was useless:?my insurance wouldn't have covered the costs if I'd used the referral. So I had to call the number on the back of the card to figure out if there was an approved doctor in the Marquette area who I could get a referral from.

When I first moved to Marquette five years ago, I made this same phone call and was told that the nearest approved doctor was in Wisconsin and there was not a single approved physician in the U.P.

Luckily for me, five years ago I had two other insurances that would pick up whatever charges my HMO denied. So I decided to just pick a doctor and stick with him. He left town this past year, so switching doctors to get a referral a few weeks ago was an easy decision.

I am grateful that my insurance will pay for my medical bills, especially after that last customer service representative I talked to stayed on the phone with me for an hour while I tried to find a doctor who would see me right away.